Effect of hemopurification on acute chlorfenapyr poisoning / 中华急诊医学杂志

Objective:To evaluate the therapeutic effect of hemopurification on acute chlorfenapyr poisoning according to the blood concentration of chlorfenapyr and to provide experience for clinical treatment.Methods:Two patients who presented to our Emergency Department following an ingestion of chlorfenapyr and then were treated with hemopurification in 2022 were included. The concentrations of chlorfenapyr and its highly toxic metabolite tralopyril were dynamically monitored, and the clinical data of the patients were collected.Results:Case 1 was given hemoperfusion for the first time 13 hours after ingestion. During l hour hemoperfusion, the tralopyril decreased by 28.82%. The concentration increased and exceeded the pre-perfusion level after 2 hours of hemoperfusion. After three times of hemoperfusion, the concentrations of chlorfenapyr and tralopyril were still higher than those before the first time, reaching 248 ng/mL and 1 307 ng/mL respectively. The concentration of chlorfenapyr showed a downward trend after 130 h, and the tralopyril in blood reached the peak 3 164 ng/mL at 130 h and decreased to 2 707 ng/mL at 178 h. In case 2, the blood chlorfenapyr and tralopyril concentration was 392 ng/mL and 7 598 ng/mL respectively 150 hours after ingestion. The blood chlorfenapyr concentration decreased by 37.75% respectively after first hemoperfusion, and the tralopyril concentration decreased by 38.02% respectively. During 85 hours of continuous veno-venous hemodiafiltration (CVVHDF), the concentration of tralopyril was maintained at 4 234~6 410 ng/mL. Case 1 was followed up to 12 days and lost follow-up. Case 2 died and the survival time was 247 hours.Conclusions:Hemoperfusion can scavenge tralopyril, but CVVHDF has poor scavenging ability for tralopyril. And the apparent volume of distribution (Vd) of chlorfenapyr and tralopyril are large. After ingestion, chlorfenapyr spreads to various tissues quickly, and it is easy to accumulate in the adipose tissue. The chlorfenapyr in the tissue slowly is released back to the blood and stays in the blood for a long time. The peak concentration of chlorfenapyr appeared earlier than that of tralopyril. Clinicians should pay attention to the early removal of toxins from the digestive tract.

Case series: Diquat poisoning with acute kidney failure, myocardial damage, and rhabdomyolysis.

Diquat is a herbicide that can have deleterious effects on the kidneys, liver, heart, lungs, and central nervous system on ingestion. Diquat poisoning-associated rhabdomyolysis has rarely been reported. We describe two cases of diquat poisoning with acute renal failure, myocardial damage, and rhabdomyolysis. Case 1: A 17-year-old man experienced anuria after ingesting ~200 mL of diquat 16 h prior. On admission, his creatinine (400 µmol/L), urea (11.7 mmol/L), creatine kinase (2,534 IU/L), and myohemoglobin (4,425 ng/mL) concentrations were elevated. Case 2: An 18-year-old woman who ingested ~200 mL of diquat 5.5 h prior to admission had normal creatinine, urea, and creatine kinase concentrations. Eleven hours after ingestion, she developed anuria with elevated creatinine (169 µmol/L) concentration; her creatine kinase (13,617 IU/L) and myohemoglobin (>3,811 ng/mL) concentrations were remarkably elevated 24 h after ingestion. Both patients also had elevated aminotransferase and myocardial enzyme concentrations. After undergoing hemoperfusion and hemofiltration, blood diquat concentrations in cases 1 and 2 on admission (16/6 h after ingestion), after hemoperfusion (20/11 h after ingestion), and after 8 h of hemofiltration/8 h of hemofiltration and 2 h of hemoperfusion (29/21 h after ingestion) were 4.9/9.1, 3.4/5.4, and 1.5/1.2 µg/mL, respectively. Severe diquat poisoning can cause acute kidney failure and rhabdomyolysis. Rhabdomyolysis may induce myocardial injury, aggravating kidney damage, and also increase transaminase concentration. Hemoperfusion and hemofiltration could be effective treatments for eliminating diquat in the blood.

Case Report: Delayed Lung Transplantation With Intraoperative ECMO Support for Herbicide Intoxication-Related Irreversible Pulmonary Fibrosis: Strategy and Outcome.

Background: Lung transplantation is recognized as the only therapeutic option for patients who develop irreversible pulmonary fibrosis after herbicide intoxication. Methods: We have collected and presented clinical course and outcome of four patients who received lung transplantation due to paraquat and diquat intoxication from 2018 to 2021. Another patient who received initial lung transplantation due to paraquat intoxication and re-transplantation due to chronic lung allograft dysfunction in 2019, was further reported. Patients were admitted in lung transplantation centers, including the 1st affiliated hospital of Zhengzhou University and Wuxi Lung transplantation center. Previous reported cases from Europe, Canada and China were also summarized as benchmark. Results: During the period from the year of 2018 to 2021, there have been four patients in China, who received lung transplantation due to herbicide intoxication. Median age of the four patients was 37 (IQR 34.5, 39.75) years old. Median time from intoxication to lung transplantation was 27.5 (IQR 27, 30.5) days. Bilateral lung transplantation was performed in three patients, while one single lung transplantation was performed in an urgent listed patient. Extracorporeal Membrane Oxygenation (ECMO) and hemopurification support were used in all patients (100%). Details of the cases with follow-ups were further presented and analyzed. Conclusions: Late timing of bilateral lung transplantation can be performed successfully for pulmonary fibrosis after paraquat or diquat intoxication. The survival of patients with complex perioperative conditions can be achieved with a multidisciplinary team to manage the irreversible effects of intoxication.

Effect of hemodialysis combined with blood perfusion and comprehensive nursing intervention on the levels of interleukin-6, C-reactive protein and β2-microglobulin in patients with diabetic nephropathy / 中国实用护理杂志

Objective To investigate the effects of hemodialysis combined with hemopurification and comprehensive nursing intervention on the levels of interleukin -6 (IL-6), C-reactive protein (CRP) and β2- microglobulin (β2- MG) in patients with diabetic nephropathy (DN). Methods A total of 68 patients with DN were selected in our hospital, and were treated with hemodialysis combined with hemopurification. The control group was treated with routine nursing intervention, and the observation group was given comprehensive nursing intervention, with 34 cases in each group. The differences in the levels of IL- 6, CRP and β2- MG before and after treatment were compared between the two groups. Results In the control group, the level of IL-6 before treatment [(121.85±34.95) pg/ml] and 1 month after treatment [(120.53 ± 24.95) pg/ml] and 3 months [(119.05 ± 25.73) pg/ml] showed no significant difference (P>0.05). The level of IL-6 in the observation group for 1 month after treatment [(98.90±20.52) pg/ml] and 3 months [(70.32 ± 10.43) pg/ml] was significantly lower than that before treatment, and significantly lower than those in the control group (P<0.05). There was no significant difference in the level of CRPbetween the control group before treatment [(12.64 ± 3.08) mg/L] and 1 month after treatment (12.64±3.15) mg/L] and 3 months [12.89±4.02] mg/L] (P>0.05); the level of CRP at 1 month after treatment [(9.24 ± 3.24)mg/L] and 3 months after treatment [(7.04 ± 2.54)mg/L] in the observation group was significantly lower than that before the treatment, and significantly lower than those in the control group (P<0.05).The level of β2-MG in the control group at 1 month [(10.24±1.79) mg/L] and 3 months after treatment [(9.01 ± 1.47) mg/L] were significantly lower than before the treatment (12.53 ± 3.45) mg/L];thelevel of β2-MG at 1 month [(9.03±1.68) mg/L] and 3 months after treatment [(6.73±1.73)mg/L] in the observation group was also significantly lower thanthat before the treatment, and significantly lower than those in the control group (P<0.05). Conclusions Hemodialysis combined with hemopurification and comprehensive nursing intervention can effectively inhibit the release of inflammatory factors and reduce the inflammatory state, so it has good clinical application value.

Efficacy of initial haemopurification strategy for acute paraquat poisoning in adults: study protocol for a randomised controlled trial (HeSAPP).

INTRODUCTION: Paraquat (PQ) is a widely used herbicide which is inexpensive and easily accessible for people in rural areas. A small amount of PQ ingestion could be lethal, yet currently, the optimal treatment is still controversial. Extracorporeal therapies (ECTR) have been practised in PQ poisoning management, though limited evidence could be obtained to suggest its superiority over conservative therapy. Haemodialysis (HD) and haemoperfusion (HP) are most commonly used, while some institutions also choose HP-HD concurrent therapy. The object of the present trial is to investigate whether haemopurification therapy can reduce mortality compared with conservative therapy. METHODS AND ANALYSIS: This is a planned single-centre, non-blinded, randomised controlled trial. Acute PQ poisoned adults who have orally ingested PQ within 24 hours would be recruited. A total of 360 patients would be recruited and randomly assigned to four groups, that is, HP, HD, concurrent HP-HD and control, at a 1:1:1:1 ratio. Subjects would be also stratified by their urine dithionite test results. Primary outcome is 28-day all-cause mortality. Secondary outcomes include survival time, all-cause mortality at the 3rd, 7th and 60th day, rate of major complications, Acute Physiologic and Chronic Health Evaluation score and Poisoning Severity Score, etc. ETHICS AND DISSEMINATION: The protocol and informed consent documents have been approved by the Ethics Committee of The First Affiliated Hospital of Zhengzhou University in September 2017 (approval number: 2017-KY-10). The result of this trial would be submitted to peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT03314909; Pre-results.

Effect of hemoperfusion combined with continuous veno-venous hemofiltration on acute paraquat poisoning:a Meta-analysis / 中华危重病急救医学

Objective To comprehensively evaluate the clinical efficacy of hemoperfusion (HP) combined with continuous veno-venous hemofiltration (CVVH) on acute paraquat poisoning (APP).Methods Literatures of Chinese and English randomized controlled trials (RCTs), case control and cohort study on HP combined with CVVH in the treatment of APP from the PubMed, Embase, Wanfang, and CNKI up to November 2017 were enrolled (the subjects were > 16 years old). The obtained literatures were strictly screened and evaluated in quality, and data such as mortality, the life time of dead patients, inefficiency rate, incidence of multiple organ dysfunction syndrome (MODS) and acute respiratory distress syndrome (ARDS) were extracted. Meta-analysis was performed by RevMan 5.3. Results Twenty-one studies were included with 2222 subjects, among whom 976 subjects were in HP combined with CVVH group (experimental group) and 1246 subjects in HP group (control group). Compared with control group, the mortality in experimental group were significantly decreased [43.77％ (362/827) vs. 55.26％ (604/1093), odds ratio (OR) =0.68, 95％ confidential interval (95％CI) = 0.56-0.82,P = 0.0001], the life time of death patients was significantly prolonged [mean difference (MD) = 4.63, 95％CI = 2.60-6.66,P < 0.00001], incidence of MODS [25.93％ (70/270) vs. 55.36％ (155/280),OR = 0.26, 95％CI = 0.14-0.49,P< 0.0001], and incidence of ARDS [30.37％ (82/270) vs. 51.07％(143/280),OR = 0.42, 95％CI = 0.30-0.61,P < 0.00001], and inefficiency rate [8.72％ (13/149) vs. 34.64％ (53/153),OR=0.17, 95％CI = 0.09-0.34, P < 0.00001] were significantly reduced. Funnel chart showed that except the publication bias of mortality rate, there were less publication bias about other indicators among studies.Conclusion HP combined with CVVH can significantly reduce the mortality of patients with APP compared with HP alone on the whole, prolong the life time and reduce the occurrence of MODS and ARDS, thus improving the treatment efficiency.

Clinical observation on the treatment effect for pruritus in uremic patients by different dialysis modalities / 重庆医学

Objective To study the effect of different dialysis modalities on pruritus in uremic patients .Methods Patients with maintenance hemodialysis who were suffered with severe cutaneous pruritus were randomly divided into hemodialysis group (HD group) ,hemodialysis combined with hemodiafiltration group (HD+ HDF group) ,hemodialysis and hemodiafiltration combined with hemoperfusion group (HD+ HDF+ HP group) .Plasma P3+ ,parathyroid hormone (PTH) and β2-microglobulin (β2-MG) were measured at pre-dialysis ,1 weeks ,4 weeks and 12 weeks after dialysis ,cutaneous pruritus was scored too .Results Compared with pre-dialysis ,the level of plasma P3+ ,PTH ,β2-MG and the scores of cutaneous pruritus were significantly lower at 4 weeks and 12 weeks after dialysis in HD+ HDF+ HP group (P<0 .05) .The were statistically significant difference in P3+ ,PTH ,β2-MG and cu-taneous pruritus scores among 3 groups after 12 weeks (P<0 .05) .Conclusion HD+ HDF+ HP is superior to HD+ HDF in effi-ciently clear P3+ ,PT H andβ2-M G ,and relief cutaneous pruritus and itching .